PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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6,254 reports
· Page 104 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 7 Aug 2015 |
Amanda Ellams
Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone …
|
BMI Healthcare GTD Healthcare | Partially Responded | 1/2 |
| 7 Aug 2015 |
Kathleen Neville
The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a …
|
Welsh Assembly Government NHS Wales | Historic (No Identified Response) | 0/2 |
| 6 Aug 2015 |
Thomas Thurling
Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a …
|
Norfolk and Suffolk NHS Foundation … | All Responded | 1/1 |
| 6 Aug 2015 |
Robert Hogg
NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite …
|
Department of Health and Social … | All Responded | 2/1 |
| 5 Aug 2015 |
Rubel Ahmed
Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial …
|
Home Office Ministry of Justice | Partially Responded | 1/2 |
| 4 Aug 2015 |
Jeffrey Warren
Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work …
|
West Sussex County Social Services Crawley Borough Council | Partially Responded | 1/2 |
| 3 Aug 2015 |
Michael Quinn
Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal …
|
Royal Berkshire Hospital Trust | Historic (No Identified Response) | 0/1 |
| 30 Jul 2015 |
Anthony Dwyer
The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs …
|
Department of Health and Social … | All Responded | 1/1 |
| 30 Jul 2015 |
Giuseppina Incisivo
Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary …
|
Department for Transport | All Responded | 1/1 |
| 30 Jul 2015 |
Casey Garrett
Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to …
|
Health Education East of England | All Responded | 1/1 |
| 28 Jul 2015 |
William Bows
There was a lack of protocols and guidance for primary and secondary care providers on monitoring patients prescribed …
|
Northern General Hospital | All Responded | 1/1 |
| 27 Jul 2015 |
Arthur Cook
Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across …
|
Cwm Taf University Health Board Aneurin Bevan University Health Board Bryntirion Surgery National Assembly for Wales Four Season’s Healthcare Home | Historic (No Identified Response) | 0/5 |
| 24 Jul 2015 |
Simon Reynolds
Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing …
|
Avon and Wiltshire Mental Health … | Historic (No Identified Response) | 0/1 |
| 24 Jul 2015 |
Carl Smith
Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information …
|
HMP Exeter Dorset Health Care University NHS … | Partially Responded | 1/2 |
| 24 Jul 2015 |
Miriam Smith-Cox
A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by …
|
Cornwall Council Devon and Cornwall Police Adult … Pluss Work Choice | Partially Responded | 2/3 |
| 23 Jul 2015 |
Lynn Poyser
Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, …
|
Medicines and Healthcare products Regulatory … Lincolnshire Community Health Services National Institute for Health and … | Historic (No Identified Response) | 0/3 |
| 23 Jul 2015 |
Doreen England
The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in …
|
Birmingham and Solihull Mental Health … NHS England Department of Health and Social … | Partially Responded | 1/3 |
| 23 Jul 2015 |
Michael Hanlon
An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised …
|
Plateus Ltd | All Responded | 1/1 |
| 23 Jul 2015 |
Ashley Matthews
Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs …
|
British Transport Police | All Responded | 1/1 |
| 22 Jul 2015 |
James McGeown
An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant …
|
Worcestershire County Council | Historic (No Identified Response) | 0/1 |
| 21 Jul 2015 |
Anne Wilson
Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on …
|
Metropolitan Police London Ambulance Service | Partially Responded | 1/2 |
| 21 Jul 2015 |
Rachel Hollister
The provided text describes the circumstances of death but does not explicitly state specific concerns or systemic failures …
|
Unknown | 0/0 | |
| 20 Jul 2015 |
Bradley Hooper
An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club …
|
M C Federation Portsmouth Motocross Club | Partially Responded | 1/2 |
| 20 Jul 2015 |
Paul Coxon
Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on …
|
Gateshead Council | All Responded | 1/1 |
| 20 Jul 2015 |
Luke Myers
HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff …
|
National Offenders Management Service | All Responded | 1/1 |
| 20 Jul 2015 |
Edward Maher, James Dunsby and Craig Roberts
A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness …
|
All Responded | 1/0 | |
| 17 Jul 2015 |
Masoud Ghaderi
Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments …
|
Avon and Wiltshire Mental Health … Care Quality Commission | Partially Responded | 1/2 |
| 17 Jul 2015 |
Adam Connelly
The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant …
|
British Transport Police Network Rail | Partially Responded | 1/2 |
| 16 Jul 2015 |
John Lloyd
Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and …
|
University Hospital of Wales | Historic (No Identified Response) | 0/1 |
| 16 Jul 2015 |
Stanley Oliver
The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out …
|
Salford Royal NHS Foundation Trust Department of Health and Social … | All Responded | 2/2 |
| 16 Jul 2015 |
Isabella Drew
Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 15 Jul 2015 |
Karen O’Brien
The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. …
|
Unknown | 0/0 | |
| 15 Jul 2015 |
Joyce Hartford
Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits …
|
Pennine Acute Hospitals NHS Trust | All Responded | 1/1 |
| 15 Jul 2015 |
Paul Kalnins
Communications officers lacked current training and struggled with a complex database where critical risk information was not easily …
|
Metropolitan Police | All Responded | 1/1 |
| 14 Jul 2015 |
Thomas Farrell
The care home failed to obtain a full prescription history from the GP, resulting in critical medications not …
|
Springfield Care Home | Historic (No Identified Response) | 0/1 |
| 14 Jul 2015 |
Kenneth Bailey
Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to …
|
Greater Manchester Fire and Rescue … | All Responded | 1/1 |
| 14 Jul 2015 |
Emma Carpenter
Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school …
|
Department for Education NHS England Department of Health and Social … | All Responded | 3/3 |
| 14 Jul 2015 |
Janine Kaiser
A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in …
|
Stoke-on-Trent City Council New Park Residential Home | Partially Responded | 1/2 |
| 13 Jul 2015 |
Barbara Harrison
Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading …
|
BMI Healthcare Limited | Historic (No Identified Response) | 0/1 |
| 13 Jul 2015 |
Wiktoria Was
Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately …
|
Metropolitan Police | All Responded | 1/1 |
| 13 Jul 2015 |
Douglas Birch
Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from …
|
HMP Swaleside | All Responded | 1/1 |
| 10 Jul 2015 |
Dorothy McDermott
A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for …
|
Littleborough Care Home Pennine Care Trust Rochdale Metropolitan Borough Council Department of Health and Social … | Historic (No Identified Response) | 0/4 |
| 10 Jul 2015 |
Cameron Laing
Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The …
|
Ministry of Defence | All Responded | 1/1 |
| 10 Jul 2015 |
Colin Moulton
Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the …
|
North West Ambulance Service Department of Health and Social … | Partially Responded | 1/2 |
| 9 Jul 2015 |
Toni Piel
A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk …
|
Department of Health and Social … Pennine Acute Hospitals NHS Trust | Partially Responded | 1/2 |
| 9 Jul 2015 |
Michael George
Senior management failed to act on previous PFD reports concerning inadequate physical healthcare, including missing consultant physician visits …
|
South London and Maudsley Trust | All Responded | 1/1 |
| 9 Jul 2015 |
Alun Walters
The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked …
|
Cwm Taf University Health Board National Assembly for Wales Lawn Medical Aneurin Bevan University Health Board Practice North Community Mental Health Team | Historic (No Identified Response) | 0/6 |
| 8 Jul 2015 |
Ronald Laidiar
The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the …
|
Greater Manchester Police | Historic (No Identified Response) | 0/1 |
| 8 Jul 2015 |
Meryl Parry
A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a …
|
Cumbria County Council Green Lane Care Homes Limited | Partially Responded | 1/2 |
| 7 Jul 2015 |
Michael Thorley
There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police …
|
Greater Manchester Police | All Responded | 1/1 |
Amanda Ellams
Partially Responded
Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone system collectively contributed to significant care failures.
BMI Healthcare
GTD Healthcare
Kathleen Neville
Historic (No Identified Response)
The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in …
Welsh Assembly Government
NHS Wales
Thomas Thurling
All Responded
Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental …
Norfolk and Suffolk NHS …
Robert Hogg
All Responded
NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite prior investigations.
Department of Health and …
Rubel Ahmed
Partially Responded
Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial information like removal directions was not shared.
Home Office
Ministry of Justice
Jeffrey Warren
Partially Responded
Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work staff inappropriately requested police for non-urgent welfare …
West Sussex County Social …
Crawley Borough Council
Michael Quinn
Historic (No Identified Response)
Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection …
Royal Berkshire Hospital Trust
Anthony Dwyer
All Responded
The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.
Department of Health and …
Giuseppina Incisivo
All Responded
Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary warning systems leads to over-reliance on mirrors …
Department for Transport
Casey Garrett
All Responded
Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and …
Health Education East of …
William Bows
All Responded
There was a lack of protocols and guidance for primary and secondary care providers on monitoring patients prescribed Amiodarone, particularly concerning liver, thyroid, and respiratory …
Northern General Hospital
Arthur Cook
Historic (No Identified Response)
Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure …
Cwm Taf University Health …
Aneurin Bevan University Health …
Bryntirion Surgery
National Assembly for Wales
Four Season’s Healthcare Home
Simon Reynolds
Historic (No Identified Response)
Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.
Avon and Wiltshire Mental …
Carl Smith
Partially Responded
Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.
HMP Exeter
Dorset Health Care University …
Miriam Smith-Cox
Partially Responded
A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by a key support stakeholder, preceding a fatal …
Cornwall Council
Devon and Cornwall Police …
Pluss Work Choice
Lynn Poyser
Historic (No Identified Response)
Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and …
Medicines and Healthcare products …
Lincolnshire Community Health Services
National Institute for Health …
Doreen England
Partially Responded
The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward suffered from inadequate …
Birmingham and Solihull Mental …
NHS England
Department of Health and …
Michael Hanlon
All Responded
An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.
Plateus Ltd
Ashley Matthews
All Responded
Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs for high voltage cabling on the bridge.
British Transport Police
James McGeown
Historic (No Identified Response)
An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant risk to unsuspecting drivers.
Worcestershire County Council
Anne Wilson
Partially Responded
Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, leading to critical …
Metropolitan Police
London Ambulance Service
Rachel Hollister
Unknown
The provided text describes the circumstances of death but does not explicitly state specific concerns or systemic failures identified by the coroner.
Bradley Hooper
Partially Responded
An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club rules for marshall allocation were not followed, …
M C Federation
Portsmouth Motocross Club
Paul Coxon
All Responded
Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on a complex slip road where driver visibility …
Gateshead Council
Luke Myers
All Responded
HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid training, raising concerns …
National Offenders Management Service
Edward Maher, James Dunsby and Craig Roberts
All Responded
A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness guidance, and risk assessment staff were untrained. …
Masoud Ghaderi
Partially Responded
Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward …
Avon and Wiltshire Mental …
Care Quality Commission
Adam Connelly
Partially Responded
The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant risk of future fatalities that Network Rail …
British Transport Police
Network Rail
John Lloyd
Historic (No Identified Response)
Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and …
University Hospital of Wales
Stanley Oliver
All Responded
The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on weekends, despite identifying …
Salford Royal NHS Foundation …
Department of Health and …
Isabella Drew
All Responded
Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers …
NHS England
Department of Health and …
Karen O’Brien
Unknown
The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of …
Joyce Hartford
All Responded
Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits and posing recurrent patient safety risks.
Pennine Acute Hospitals NHS …
Paul Kalnins
All Responded
Communications officers lacked current training and struggled with a complex database where critical risk information was not easily accessible or prominently displayed, jeopardising vulnerable persons.
Metropolitan Police
Thomas Farrell
Historic (No Identified Response)
The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk …
Springfield Care Home
Kenneth Bailey
All Responded
Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to undertake dangerous rescues, increasing their risk of …
Greater Manchester Fire and …
Emma Carpenter
All Responded
Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication between mental health …
Department for Education
NHS England
Department of Health and …
Janine Kaiser
Partially Responded
A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in record-keeping and mattress management. Referrals to specialists …
Stoke-on-Trent City Council
New Park Residential Home
Barbara Harrison
Historic (No Identified Response)
Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were …
BMI Healthcare Limited
Wiktoria Was
All Responded
Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and …
Metropolitan Police
Douglas Birch
All Responded
Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. They also did …
HMP Swaleside
Dorothy McDermott
Historic (No Identified Response)
A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance …
Littleborough Care Home
Pennine Care Trust
Rochdale Metropolitan Borough Council
Department of Health and …
Cameron Laing
All Responded
Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach …
Ministry of Defence
Colin Moulton
Partially Responded
Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to …
North West Ambulance Service
Department of Health and …
Toni Piel
Partially Responded
A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk factors, violating NICE guidelines on patient observation.
Department of Health and …
Pennine Acute Hospitals NHS …
Michael George
All Responded
Senior management failed to act on previous PFD reports concerning inadequate physical healthcare, including missing consultant physician visits and inconsistent glucose testing, for mental health …
South London and Maudsley …
Alun Walters
Historic (No Identified Response)
The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR …
Cwm Taf University Health …
National Assembly for Wales
Lawn Medical
Aneurin Bevan University Health …
Practice
North Community Mental Health …
Ronald Laidiar
Historic (No Identified Response)
The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the source of blood, or identify a key …
Greater Manchester Police
Meryl Parry
Partially Responded
A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a serious risk that discharged individuals will not …
Cumbria County Council
Green Lane Care Homes …
Michael Thorley
All Responded
There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police failed to thoroughly investigate the scene, overlooked …
Greater Manchester Police